Healthcare Provider Details

I. General information

NPI: 1275980278
Provider Name (Legal Business Name): BREESHA DONAHUE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 SPRINGHILL DR STE 100-B
NORTH LITTLE ROCK AR
72117-2910
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-955-4530
  • Fax: 501-955-4540
Mailing address:
  • Phone: 501-812-7215
  • Fax: 501-812-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8122-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8122-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: